A question for the forum.
We(perfusionists) add potassium to our plegisol. Some of us make up the bags with the additive and store it in a refrigerator. Is there a time limit regarding how long they can be stored before use?

Our OR manager has consulted the pharmacy and they say 24hrs is the maximum and that now is the the new rule.

At a previous job the pharmacy made up the cardioplegia (in batches of 30 or more)and it was stored in a fridge for more than 24 hrs.

How ds one determine when a rule is science based or just 'the way we do it here?']]>
Thu, 27 Jul 2017 08:28:39 +0000http://www.perfusion.com/cgi-bin/forum/forum_posts.asp?TID=612&PID=1441#1441Adult Perfusion : Perfusion call back payhttp://www.perfusion.com/cgi-bin/forum/forum_posts.asp?TID=610&PID=1439#1439
Author: tiffe2002Subject: Perfusion call back payPosted: Apr 10 2017 at 11:34am

I am just curious how other centers are basing their Perfusion salary. Would just like to know what the average salary scale is and if that includes call back pay or if you get call back pay separately from your base salary. I realize that every center is different based on practice but am trying to get an average for the country. Also, if you do get separate call back pay, how is it metered? By hour, by case?

Dana,
This is late but I thought I'd share my roles. I transitioned into multitasking in 1996 as an RN/CCP. We ran perfusion, POCT, STS data collection and surgical assisting via SVG harvest/wound closure/2nd assist, etc... After surgery we transferred the patient and help the CICU RNs recover the patients for 3-5 hours and were the 2nd set of eyes for the surgeons we worked for. After moving on my practice went to assisting Anesthesia with Swans, A-lines then supporting Gen. surgery after our hearts, STS, 3 different committees and providing inservices for the OR staff. The gamut is vast but that's my distant experience. ]]>
Thu, 17 Nov 2016 17:12:54 +0000http://www.perfusion.com/cgi-bin/forum/forum_posts.asp?TID=599&PID=1437#1437Adult Perfusion : BE vs Lactatehttp://www.perfusion.com/cgi-bin/forum/forum_posts.asp?TID=604&PID=1436#1436
Author: racineSubject: BE vs LactatePosted: Nov 15 2016 at 2:37pm

Serum Lactate has always been a part of the whole picture. Whether one calculates Op Mort data preop, evaluates all co-morbidities, etc. pH/Base Deficits, and serum lactate, each case is different. I guess I've always read more into the H&P and based my conduct of bypass on all these parameters. What I've found myself doing on occasion is responding to elevated Serum Lactate levels by emphasizing myocardial protection and CI changes despite normal ABG values. It was not uncommon to find Lactate levels approaching high single digits with normal ABGs and even seeing Lactate levels in the double digits on prolonged cases. All in all, I prefer to stay out of deep water and having this value is a vital predictor of outcomes from weaning off CPB to avoiding heavy inotropic support or other mechanical support at the end of the operation.
Just my thoughts...
]]>
Tue, 15 Nov 2016 14:37:31 +0000http://www.perfusion.com/cgi-bin/forum/forum_posts.asp?TID=604&PID=1436#1436Adult Perfusion : Adult ECMOhttp://www.perfusion.com/cgi-bin/forum/forum_posts.asp?TID=565&PID=1433#1433
Author: mmeenenSubject: Adult ECMOPosted: Oct 10 2016 at 6:46pm

How are you? I hope you are all doing well. I have a few questions in regards to staffing for call and ECMO, and I hope you all don't mind answering. The first question is how many perfusionists are on your team? Secondly, how ds your call rotation work? Is it a week at a time or is it broken up? Aside from PTO are there any days off or "comp" days built into your schedule? Do you like your current schedule? If you could tweek something what would you tweek? Are you an ECMO center? If so how ds ECMO affect your call? Once the ECMO is initiated, who monitors it? (Perfusion,nursing or respiratory). If perfusion monitors it, is it in-house staff or per-diem, and do you sit bedside? Are you compensated for the E-shifts you watch? If so is it an hourly rate or a lump sum? (I don't need to know the rate, or the sum). If your center has nursing or respiratory monitor the ECMO's how do you like that model? I realize I just asked you a lot of questions. You may not feel comfortable answering some or any of them. Which ever questions you choose to answer I will greatly appreciate it. Thank you so much for taking the time to read this post.

Hey Paige,
While many perfusion departments only monitor base deficit, there is significant evidence that intraoperative serum lactate levels may be an indicator of tissue perfusion and also predictor of mortality. Base deficit monitoring alone may not be best practice.

Martin, et al. showed that both lactate and base deficit levels may be used to identify lactic acidosis and predict mortality at admission to the ICU. Increased lactate levels predict mortality and a prolonged course regardless of the associated base deficit level, whereas an increased BD level has no predictive value if the lactate level is normal. This article is somewhat misleading but concludes that base deficit monitoring alone may not be reliable in predicting mortality and care plan.

De Somer published an article in JECT where he investigated principles of cardiac output, anÆrobic metabolism, and how to estimate organ perfusion during CPB. While he ds not collect or present any data, De Somer recommends that carbon dioxide-derived parameters in combination with intermittent whole blood lactate levels provide inline information regarding tissue perfusion, allowing the perfusionist to proactively intervene to optimize tissue perfusion during CPB.

My thought is that both serum lactate and base deficit monitoring be utilized in ensuring adequacy of perfusion. My recommendation for best practice is that a baseline lactate level be taken prior to CPB, at initiation and every hour. In addition, the base deficit should be monitored and treated accordingly. If lactate levels are >4mmol/L, an increase in flow rate, MAP, or etc should occur to ensure adequacy of perfusion.

In recent years, the heavy excavator has become one of the most important construction machinery. Here are some important tips on heavy excavator operation safety protection measures.

When transfer an heavy excavator to construction site, the heavy excavator should be transported by using a tractor-trailer. When it needed to be transported under special circumstances, it should be removed arm and bucket rotating parts and be fixed at first. It should be carried on inspection, and lubrication for the heavy excavators is needed when walking for every 500-1000m. If the heavy excavator walks on the soft ground, sleepers and pads should be put on the ground. If the heavy excavator works in the swamp areas, subgrade treatment should be dealt with and special track shs need to be replaced. It is strictly prohibited from mining without blasting five-level rocks or frozen ground.
]]>
Sun, 05 Jun 2016 21:39:57 +0000http://www.perfusion.com/cgi-bin/forum/forum_posts.asp?TID=605&PID=1428#1428Adult Perfusion : BE vs Lactatehttp://www.perfusion.com/cgi-bin/forum/forum_posts.asp?TID=604&PID=1427#1427
Author: ablakey86Subject: BE vs LactatePosted: Jun 05 2016 at 12:57pm

Hello Paige,

This is an interesting topic that you bring up. I do not think there is one single Âmagic bulletÂ parameter to assess the adequacy of perfusion. I believe we have to look at the global picture of the patient, taking into account all factors: svO2, BE, cerebral oximetry, lactate, etc. As far as blood gas values that determine if there is hypoperfusion occurring, both base excess and lactate have been used in conjunction, or independently to assess perfusion.

The rationale behind using lactate as a marker for adequacy of perfusion is that lactate is produced under anÆrobic conditions at the cellular level. The measurement of base excess has been used as a surrogate for lactate production, but that rational has been found to be faulty. In fact, in a study by Milkulaschek et al, it was shown that there is no correlation between lactate and base excess and that lactate must be measured directly.

Using base excess as an independent indicator of hypoperfusion can even lead to an inappropriate clinical intervention believing lactate is rising. Brill et al showed that hyperchloremia can cause a large base deficit in the absence of hyperlactemia. Hyperchloremia occurs when large volumes of normal saline or another chloride containing solution are given to a patient relative to their blood volume (most prevalent in pediatrics and massive transfusion traumas).

Lactate measurement can also be used as a strong indicator of morbidity and mortality. Noval-Padillo et al. measured the lactates of heart transplant patients upon arriving in the ICU, and found that patients with lactates of >4 mmol/L had an 18.7% risk of morbidity and mortality compared to 6.2% for the patients with lactates <4 mmol/L. Lactate clearance in particular correlates strongly with morbidity and mortality. Husain et al found that if lactate could be normalized within 24 hours, survival of shock patients was 90%, compared to 33% if lactate didnÂt clear within the first 24 hours.

Base excess measurement still holds value in certain acid-base derangements where lactate ds not. Lactate levels have no bearing on other types of acidosis like respiratory, hyperchloremia, or ketoacidosis.

While lactate measurement may be the best blood gas value we have to assess the adequacy of perfusion, it is not perfect, and should be used in conjunction with base excess to assess the patients metabolic needs.